COLUMN LEFT : Don’t Settle for Crumbs on Health Reform : Boldness by Clinton and Congress could bring a medical care revolution.

After nearly a three-decade hiatus, the time has come for fundamental reform of our medical care. Many Americans have demanded far-reaching changes in access to and the financing of our troubled system, and Gov. Bill Clinton made the problems of American medicine a major feature of his campaign. Rarely has a President been swept into office with so clear a mandate for change as Clinton.

In such circumstances, neither the Clinton Administration nor Congress should rely on reform plans proposed before the election. The old proposals--whether “play or pay” plans or “managed competition” or tinkering with the rules of private health insurance--were crafted in a different political context.

They presumed the need to build a policy consensus between a Democratic Congress and a Republican President. They proceeded from now-outdated assumptions about political possibilities. Clinton’s dramatic win transforms the political setting. And with that should come a broadened agenda to reform a world of medical care practically everyone believes is seriously flawed.

In fashioning that new agenda, we should heed the cautionary lessons of Medicare’s start in 1965. Despite the historic electoral landslide of 1964 that swept Democrats into Congress and the White House, reformers then proposed a limited bill (60 days of hospital coverage for the elderly) designed to minimize any risk of legislative rejection. Democrats in Congress and the White House carried over outdated myths of what could pass.

Accordingly, President Johnson’s Medicare bill of 1965 was almost exactly what had been sought in the early years of the Kennedy Administration, when a coalition of conservative Democrats and Republicans dominated Congress. The excessive fear of defeat prevented the advocates of change from staking out and fighting for their fundamental objective--the establishment of a comprehensive, universal and administratively straightforward program of health insurance. Passing Medicare, a means to achieving fundamental reform, became the end itself.

In 1965, excessive timidity also led Democrats to accept weak controls over the government’s new financial commitments. Instead of insisting on concentrated financial responsibility, they delegated authority over the cost and quality of care to private entities--insurers acting as financial intermediaries. Medicare’s rapid cost escalation was not unexpected; knowledgeable government figures, particularly in the Bureau of the Budget, anticipated a more costly and less satisfactory service without firm public controls.

Today, a lot more is conceivable than just a few months ago. Democrats should take advantage of this in two ways. First, they should stake out the claim of comprehensive, universal health insurance by the end of President Clinton’s first term. It’s time to abandon the approach of limiting assured care to specific diseases such as kidney failure, to employment status or to demographic groups like the aged. The public is ready. Most Americans regard health care as a right, not a privilege.

Second, the new Administration and Congress should build a firm cost-containment structure. The history of health reform in Western countries suggests that when the government pays for care or mandates it, the cost of treatment will rise without countervailing administrative restraint. That means we need a national health budget and, no doubt, fee schedules for doctors and hospitals. For the special circumstances of health maintenance organizations, set budgets based on the number of persons enrolled are an effective alternative.

It is also time to abandon the old approach of micromanaging medical care, with public or private insurers intruding into the everyday decisions of doctors, nurses and patients. Establishing a firm foundation of government accountability offers a new reform path: Government involvement should be limited to macro-level decisions about the size of the health budget, leaving patients and providers greater freedom within that constraint.

The lesson of 1965 for 1993 is that fundamental health reform is worth a strenuous fight. Little is gained by avoiding political conflict over basic questions--how much is available to spend, whether medical need or income should determine priority and who is to decide precise treatments. Democrats in Congress and the White House have a glorious opportunity--and the associated risk of conflict. They have the chance to establish the basic rules for a health system of which Americans can be justly proud.